Volvulus with bowel necrosis after laparoscopic appendectomy. Migration of Clip?

Volvulus with bowel necrosis after laparoscopic appendectomy. Migration of Clip? About 2.8% of patients develop small bowel obstruction, mostly following an open approach appendectomy. Case Report: we present an 18-year-old girl with acute abdomen 10 days following laparoscopic appendectomy. An emer- gency laparotomy was performed which revealed bowel necrosis and an impacted slipped clip on the mesenterial side of the bowel with signs of bowel strangulation and necrosis. Bowel resection was carried out with primary enteroenteric anastomosis. We suspect the sharp ends of the open clip allowed it to become lodged in the bowel segment resulting in bowel obstruction and subsequent necrosis. It is possible that the clip migrated or was a failed deployment. To our knowledge, this is the firstreportofmechanicalbowel obstructionafter laparoscopic appendectomy caused by aberrant surgical clip. INTRODUCTION CASE REPORT Laparoscopic surgery is increasing in all specialties and ages. An 18-year-old female was admitted to our emergency room The rate of serious complications following laparoscopic (Spital Visp, Spitalzentrum Oberwallis) on 16 May 2017 with appendectomy is overall low. The most common complica- abdominal pain, nausea and vomiting for 7 hours. The patient’s tions observed after surgical treatment of appendicitis are medical history reported heterozygote APC-resistance (factor V superficial and deep wound infections, prolonged ileus and Leiden mutation), heterozygote mutation of factor II (positive pneumonia [1]. However, new and rare complications related family anamnesis) and asthma. to this procedure have been reported. Laparoscopic-related She had signs of peritoneal irritation on the right iliac fossa. complications occur at the time of abdominal access for cam- The ultrasound examination showed a thickened appendix era or port placement [2]. Complications can also arise from (7 mm), non-compressible, local ileocecal lymphadenopathy abdominal insufflation, tissue dissection and hemostasis [3]. without perforation or abscess, consistent with acute appendi- The rate of postoperative small bowel obstruction following citis. The diagnosis was confirmed by laparoscopy and a laparo- appendectomy (SBO) in adults is reported to be around 2.8%. scopic appendectomy was carried out on the same day. The greatest risk factors for developing SBO are midline inci- Postoperatively, she was put on Rivaroxaban 10 mg for 2 weeks. sion and nonappendicitis pathology [4]. We report a case of There were no postoperative complications and after normal an adolescent girl presenting with bowel obstruction after laboratory results, the patient was discharged after 2 days. laparoscopic appendectomy requiring exploratory laparot- After 10 days, the patient was readmitted to our hospital omy followed by a bowel obstruction 10 days later requiring with acute onset of periumbilical abdominal pain without asso- ileocecal resection. ciated nausea, vomiting, diarrhea, or dysuria. The clinical Received: February 10, 2018. Accepted: April 25, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy093/4996082 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 D. Kakaty et al. examination revealed silent bowel sounds and tenderness over patients following appendectomy have been described as being the right lower quadrant without rebound tenderness. Vital associated with adhesive band formation and subsequent signs were normal. Laboratory results showed elevated white bowel obstruction [4]. Strangulation leading to ischemia, necro- blood cells with 12.0 G/l (4.0–10.0 G/l) and an elevated lactate sis and ultimately perforation and sepsis are the most feared with 4.8 mmol/l (0.50–2.20 mmol/l). Abdominal computed tom- complication of small bowel obstruction. Although clinically, ography was performed and showed loop distension and a large there is no way to determine strangulation, suggestive signs amount of free fluid. An emergency laparotomy was carried and symptoms of ischemia include continuous pain, fever, out. The surgical finding consisted of small bowel obstruction of tachycardia, peritoneal irritation, leukocytosis and metabolic the terminal ileum with necrosis along 60 cm of the small intes- acidosis. It is generally accepted that immediate operation is tine. The necrotic bowel was then resected (ilea-cecal resection) required with a complete bowel obstruction. Intestinal obstruc- and an enteroenteric anastomosis was performed. Interestingly tion with signs of strangulation or ischemia merits an urgent we found a 6-mm metal clip, which was dislocated and wan- laparotomy. However, once conservative management is dered along the small intestine, most probably accounting for decided on, close observation of the patient is warranted. the source of volvulus. In the postoperative period, the patient Worsening of patient condition or failure of nasogastric tube evolved without intercurrences (Figs 1 and 2). treatment could lead to a change in treatment plan and opera- tive intervention as a definitive treatment. Migration of a surgical clip causing intestinal obstruction after laparoscopic appendectomy is a very rare complication. Pub Med DISCUSSION searches using the keywords ‘appendectomy,’‘surgical clip,’ or Adhesions are the most common cause of bowel obstruction ‘bowel obstruction’ yielded no articles that matched this topic. On and are associated with prior laparotomy. About 2.8% of the other hand, many reports of complications from deviant sur- gical clips exist; most common is gallstone formation around a clip resulting in choledocholithiasis. Some of the more unique tales of aberrant clips include an open staple resulting in bowel perforation after laparoscopic-assisted vaginal hysterectomy; a surgical clip found in duodenal ulcer bed status after laparoscopic cholecystectomy; a surgical clip with erosion through the esopha- gus; stone formation around a clip resulting in nephrolithiasis; expectoration of a clip after pneumonectomy; and a surgical clip protruding through the urethra after radical prostatectomy [5]. This case report of volvulus with subsequent bowel necrosis resulting from a migrated surgical clip represents a unique tale in the ongoing history of aberrant surgical clips. CONCLUSION The patient in this case study presented with bowel obstruction Figure 1: Impacted surgical clip on the mesenterial side of the small bowel wall. after an abdominal laparoscopic procedure. Based on the his- tory, it was suspected that the migrated surgical clip lodging in the abdominal wall was the likely cause of her small bowel obstruction. Ultimately, this guided the decision to choose a laparotomy as the definitive treatment in the patient with suc- cessful results (Figs 1 and 2). CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Margenthaler JA, Longo WE, Virgo KS, Johnson FE, Oprian CA, Henderson WG, Daley J, Khuri AF. Risk factors for adverse outcomes after the surgical treatment of appendi- citis in adults. Ann Surg 2003;238:59–66. 2. Magrina JF. Complications of laparoscopic surgery. Clin Obstet Gynecol 2002;45:469. 3. Trottier DC, Martel G, Boushey RP. Complications in laparo- scopic intestinal surgery: prevention and management. Minerva Chir 2009;64:339. 4. Leung TT, Dixon E, Gill M, Mador BD, Moulton KM, Kaplan GG, Maclean AR. Bowel obstruction following appendectomy: what is the true incidence? Ann Surg 2009;250:51–3. 5. Neff M, Schmidt B. Laparoscopic treatment of a post- Figure 2: Volvulus with bowel necrosis. operative small bowel obstruction. JSLS 2010;14:133–6. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy093/4996082 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Volvulus with bowel necrosis after laparoscopic appendectomy. Migration of Clip?

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

About 2.8% of patients develop small bowel obstruction, mostly following an open approach appendectomy. Case Report: we present an 18-year-old girl with acute abdomen 10 days following laparoscopic appendectomy. An emer- gency laparotomy was performed which revealed bowel necrosis and an impacted slipped clip on the mesenterial side of the bowel with signs of bowel strangulation and necrosis. Bowel resection was carried out with primary enteroenteric anastomosis. We suspect the sharp ends of the open clip allowed it to become lodged in the bowel segment resulting in bowel obstruction and subsequent necrosis. It is possible that the clip migrated or was a failed deployment. To our knowledge, this is the firstreportofmechanicalbowel obstructionafter laparoscopic appendectomy caused by aberrant surgical clip. INTRODUCTION CASE REPORT Laparoscopic surgery is increasing in all specialties and ages. An 18-year-old female was admitted to our emergency room The rate of serious complications following laparoscopic (Spital Visp, Spitalzentrum Oberwallis) on 16 May 2017 with appendectomy is overall low. The most common complica- abdominal pain, nausea and vomiting for 7 hours. The patient’s tions observed after surgical treatment of appendicitis are medical history reported heterozygote APC-resistance (factor V superficial and deep wound infections, prolonged ileus and Leiden mutation), heterozygote mutation of factor II (positive pneumonia [1]. However, new and rare complications related family anamnesis) and asthma. to this procedure have been reported. Laparoscopic-related She had signs of peritoneal irritation on the right iliac fossa. complications occur at the time of abdominal access for cam- The ultrasound examination showed a thickened appendix era or port placement [2]. Complications can also arise from (7 mm), non-compressible, local ileocecal lymphadenopathy abdominal insufflation, tissue dissection and hemostasis [3]. without perforation or abscess, consistent with acute appendi- The rate of postoperative small bowel obstruction following citis. The diagnosis was confirmed by laparoscopy and a laparo- appendectomy (SBO) in adults is reported to be around 2.8%. scopic appendectomy was carried out on the same day. The greatest risk factors for developing SBO are midline inci- Postoperatively, she was put on Rivaroxaban 10 mg for 2 weeks. sion and nonappendicitis pathology [4]. We report a case of There were no postoperative complications and after normal an adolescent girl presenting with bowel obstruction after laboratory results, the patient was discharged after 2 days. laparoscopic appendectomy requiring exploratory laparot- After 10 days, the patient was readmitted to our hospital omy followed by a bowel obstruction 10 days later requiring with acute onset of periumbilical abdominal pain without asso- ileocecal resection. ciated nausea, vomiting, diarrhea, or dysuria. The clinical Received: February 10, 2018. Accepted: April 25, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy093/4996082 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 D. Kakaty et al. examination revealed silent bowel sounds and tenderness over patients following appendectomy have been described as being the right lower quadrant without rebound tenderness. Vital associated with adhesive band formation and subsequent signs were normal. Laboratory results showed elevated white bowel obstruction [4]. Strangulation leading to ischemia, necro- blood cells with 12.0 G/l (4.0–10.0 G/l) and an elevated lactate sis and ultimately perforation and sepsis are the most feared with 4.8 mmol/l (0.50–2.20 mmol/l). Abdominal computed tom- complication of small bowel obstruction. Although clinically, ography was performed and showed loop distension and a large there is no way to determine strangulation, suggestive signs amount of free fluid. An emergency laparotomy was carried and symptoms of ischemia include continuous pain, fever, out. The surgical finding consisted of small bowel obstruction of tachycardia, peritoneal irritation, leukocytosis and metabolic the terminal ileum with necrosis along 60 cm of the small intes- acidosis. It is generally accepted that immediate operation is tine. The necrotic bowel was then resected (ilea-cecal resection) required with a complete bowel obstruction. Intestinal obstruc- and an enteroenteric anastomosis was performed. Interestingly tion with signs of strangulation or ischemia merits an urgent we found a 6-mm metal clip, which was dislocated and wan- laparotomy. However, once conservative management is dered along the small intestine, most probably accounting for decided on, close observation of the patient is warranted. the source of volvulus. In the postoperative period, the patient Worsening of patient condition or failure of nasogastric tube evolved without intercurrences (Figs 1 and 2). treatment could lead to a change in treatment plan and opera- tive intervention as a definitive treatment. Migration of a surgical clip causing intestinal obstruction after laparoscopic appendectomy is a very rare complication. Pub Med DISCUSSION searches using the keywords ‘appendectomy,’‘surgical clip,’ or Adhesions are the most common cause of bowel obstruction ‘bowel obstruction’ yielded no articles that matched this topic. On and are associated with prior laparotomy. About 2.8% of the other hand, many reports of complications from deviant sur- gical clips exist; most common is gallstone formation around a clip resulting in choledocholithiasis. Some of the more unique tales of aberrant clips include an open staple resulting in bowel perforation after laparoscopic-assisted vaginal hysterectomy; a surgical clip found in duodenal ulcer bed status after laparoscopic cholecystectomy; a surgical clip with erosion through the esopha- gus; stone formation around a clip resulting in nephrolithiasis; expectoration of a clip after pneumonectomy; and a surgical clip protruding through the urethra after radical prostatectomy [5]. This case report of volvulus with subsequent bowel necrosis resulting from a migrated surgical clip represents a unique tale in the ongoing history of aberrant surgical clips. CONCLUSION The patient in this case study presented with bowel obstruction Figure 1: Impacted surgical clip on the mesenterial side of the small bowel wall. after an abdominal laparoscopic procedure. Based on the his- tory, it was suspected that the migrated surgical clip lodging in the abdominal wall was the likely cause of her small bowel obstruction. Ultimately, this guided the decision to choose a laparotomy as the definitive treatment in the patient with suc- cessful results (Figs 1 and 2). CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Margenthaler JA, Longo WE, Virgo KS, Johnson FE, Oprian CA, Henderson WG, Daley J, Khuri AF. Risk factors for adverse outcomes after the surgical treatment of appendi- citis in adults. Ann Surg 2003;238:59–66. 2. Magrina JF. Complications of laparoscopic surgery. Clin Obstet Gynecol 2002;45:469. 3. Trottier DC, Martel G, Boushey RP. Complications in laparo- scopic intestinal surgery: prevention and management. Minerva Chir 2009;64:339. 4. Leung TT, Dixon E, Gill M, Mador BD, Moulton KM, Kaplan GG, Maclean AR. Bowel obstruction following appendectomy: what is the true incidence? Ann Surg 2009;250:51–3. 5. Neff M, Schmidt B. Laparoscopic treatment of a post- Figure 2: Volvulus with bowel necrosis. operative small bowel obstruction. JSLS 2010;14:133–6. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy093/4996082 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Journal of Surgical Case ReportsOxford University Press

Published: May 15, 2018

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